Therapy is key to recovery from knee replacements

Denise Sautters

Monday

Sep 29, 2008 at 12:01 AMSep 29, 2008 at 7:03 AM

When Harold Keith couldn't take the pain in his knees anymore, he sought the help of doctors at the Cleveland Clinic in Florida, where he was living. After three shots of cortisone in as many years, he knew it was time to do something else.

When Plain Township, Ohio, resident Harold Keith couldn't take the pain in his knees anymore, he sought the help of doctors at the Cleveland Clinic in Florida, where he was living.

After three shots of cortisone in as many years, he knew it was time to do something else.

"My knees were not going to get any better," he said. "I was at the point that I either had to have total knee replacement, or not."

Keith had both of his knees replaced in June at the Crystal Clinic in Akron, Ohio.

Knee replacement

When knees wear down, there are several options available to patients, ranging from cortisone or gel injections, which replace missing cartilage, to total knee replacement surgery. Before getting the latter, patients usually go through a series of prescription and physical therapies to strengthen the knee.

In addition to the cortisone shots he had while living in Florida, Keith said his doctor here gave him exercises to strengthen the muscles around the knee before surgery.

"Pain is the ultimate answer for the surgery," said Dr. Anthony Pentz, an orthopedic surgeon with Omni Orthopaedics in Jackson Township, Ohio. "If the pain is coming from severe wear and tear within the joint, then we recommend a knee replacement."

The surgery takes about an hour to an hour and a half, he said, noting that the operating room looks a lot like a woodshop.

"Our table doesn't look that much different than a workbench," said Pentz. "We have motorized saws and miter boxes we use to make our cuts. In a lot of ways, it is like doing carpentry on bones."

The surgeon makes a cut over the knee, the kneecap is moved out of the way, and the ends of the thigh bone and shin bone are cut to fit a prosthesis. Both parts of the prosthesis are connected to the ends of the femur, tibia and knee cap with bone cement.

Pentz said prosthetic knees come in a variety of sizes.

"We have a whole rack of replacement parts that spans the size options," he said. "Then we have templates we use so we make sure we get the exact size for the patient."

Whether or not the patient gets knees replaced one at a time or both at the same time depends on the patient. Do they have balance issues? Are they elderly? What overall condition are they in?

"I think the biggest thing is choosing the candidate appropriately," said Pentz. "If I have any doubts, I lean toward single knee surgery."

Following the operation, Pentz said the first thing doctors look at is the wound.

"We want the wound to heal successfully (without infection), then simultaneously with that, we want to train the knee to work like a knee again," he said. "In primitive times, before there were casts and doctors, the body would lay down a lot of scar tissue and it would try to heal things in place. We are sort of fighting nature's desire to heal this in a nonmoving block. We are trying to teach it to be a bending, functioning knee.

"The knee has a very complicated motion. You hear a lot of people talk about it being harder to rehabilitate the knee rather than the hip."

That is because the hip is a straightforward ball and socket joint. The knee has a fairly complex motion to it. For that reason, it typically takes longer to restore its mobility, he said.

"A normal knee can bend to about 155 degrees, to get your calf back to your thigh," said Pentz, adding that to really run its full course it takes about 15 months to heal. The first three months is the acute stage, the rest is making the prosthesis a part of you.

"Therapy is a huge key to success. I always tell patients that half of their success happens in the operating room, the other half depends on the patient."

Benefits of therapy

Jennifer Proffitt, director of therapy services at Aultman North, explains that one of the keys to physical therapy is a therapist conducting a comprehensive initial evaluation to guide the patient's care.

"At Woodlawn, the focus is on getting home," she said. "Their goal is driven toward functional mobility. When you come here, the focus is on strength and range of motion."

Not all orthopedic patients need the same therapy after knee surgery, so therapists treat each person individually.

"There is a certain protocol we have, but not a recipe," said Julia Pettitt, a physical therapist and team leader at Aultman North. "There are typical exercises patients go through that have been proven through research to be effective. However, everybody is individualized as to their progress. Some people will go faster, others slower, depending on what the specific impairments are."

If the patient is having more trouble with strength, the therapist will focus there. If the problem is range of motion, then the therapist will design a therapeutic program to help with that.

"Typically, we start with general strengthening exercises, then work toward functional activities, so they (patients) can return to their normal activities at home," she said. "Everyone gets similar activities, but it depends on how the individual progresses."

Pettitt explained that, functionally, therapists like to see patients get to 120 degrees flexion and zero degrees extension through therapy. Not all patients achieve it, but sometimes, Pettitt said, therapists are surprised with the amount of function some people have at the start of therapy.

"I've had instances where someone would come in two weeks after surgery and be able to walk circles around me. It was very impressive," she said. "Everybody progresses at their own level according to their prior level of functioning, other medical issues going on and the patient's motivation. It comes down to what the patient wants to do and what they believe they can do."

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